Scott L. Replogle, MD (retired)

In general, a replacement implant needs to be the same diameter as the previous one. The decrease in size/volume is by going to a lower profile implant. The lowest profile implant is called "low profile". So I would choose the same implant diameter as you have but with a low profile rather than a moderate plus. 

Saline-filled breast implants do not "leak toxins" assuming they were properly filled with sterile saline. They also tend to collapse at least partially rather than "leak". 

It's is important to first understand that breast implants do not actually lift the breast and address ptosis. Larger implants don't lift the breast more. The implant is like a pillow behind the breast and fills it out which can make the breast look lifted but doesn't actually lift it up. 

The way to understand sizing of implants is that for round implants the diameter of the implant needs to match the horizontal width of the breast at the base when upright and arms down (which can easily be measured). Then the forward volume of the implant is chosen by picking a "profile" of implant -- low, medium, moderate plus, or high profile. Unless the breast is unusually wide or narrow, a proper fitting diameter of implant will make the breast look between one cup size (low profile) to two cup sizes (high profile) larger. A medium profile will make the breast look about 1 1/2 cup sizes larger. The patient should consider what size she looks like now and then choose a profile for the increase desired. The number of cc's of the implant is then found by looking up the correct diameter of implant in the chosen profile. 

I would discourage you from having breast implants with a lift at the same time as a tummy tuck. It's too much surgery at the same time and would increase your worries about complications. 

You clearly need a lift as your nipple position is well below your inframammary crease level but you might consider just a lift first and then see if you want more volume. Breast implants are pure pillow volume and do not actually lift the breast. You may have enough volume that you don't need or want an implant after the lift but you can always add it later on once the nipple-areola part of the breast is elevated to the appropriate level. 

Breast lifts (mastopexy) reposition and adjust the proportions of the breast around the nipple-areola and inframammary crease. The breast can still look saggy because of lack of forward volume and upper pole fill which is what an implant provides. In your situation of excessive sag and reasonable volume, I would recommend to do only the lift first and then see if you still want/need and implant for forward volume which can be done later. 

Think of capsules around any smooth implant as a layer of scar tissue where you healed around the implant. It's not like a scar from a cut in the skin but it's the same process and there's no reason to remove it just to remove it because of what's involved and it will heal with a new layer of scar. Capsules around implants (like scars on your skin) only need or potentially benefit from removal if they're abnormal -- thickened, contracted, or tumorous. I agree with your plastic surgeon that there's no reason to remove your capsules if they are normal. 

Sizing great implants is a bit like choosing a hat that fits and how tall it is. Thinking in cc's will not get you anywhere. For round, smooth surface implants, the key is that the diameter of the implant has to fit the base width of your breast when you are upright with arms down (which can be measured easily). Subtract about 1 cm or so for the skin thickness and you know what "size" implant fits you. Your choice is the forward volume of the implant called the "profile". This is how much forward projection the implant will give as the implant is like a pillow behind your breast. The choices are generally low, medium, medium plus, and high profile. The effects of this are more difficult to measure but unless your breasts are unusually wide or narrow, a low profile implant will make you look about one cup size bigger (same chest diameter) and a high profile implant will make you look about two cup sizes larger with the medium profile in between. You find out the number of cc's by looking up the diameter that fits you and your choice of implant profile. You will also know that the implant fits you and will look natural if sub pectorally positioned. 

Breast implants are like pillows behind the breast base and do not actually lift the breast but rather fill it out forward. The "lift" effect is mainly from filling in the upper pole but will not lift the nipple-areola. The degree of sag and need for a lift is determined by where the nipple sits in relation to the inframammary crease behind it when you are upright with arms down. 

Areola reduction can definitely be done with only local anesthesia. Most plastic surgeons aren't trained in it or used to doing it but any breast procedure including breast reduction or even mastectomy can be done with local anesthesia as the entire chest can be blocked with anesthetic injections. This is usually done with IV sedation but is still local anesthesia and is easier on the system, less risk, and less cost.